Insomnia diagnosis and treatment across the lifespan

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doi:doi: 10.12788/jfp.0545

Applied Evidence

Insomnia diagnosis and treatment across the lifespan

J Fam Pract. 2023 January;72(1):18-28 | doi: 10.12788/jfp.0545

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References

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Melatonin is not recommended for treating insomnia in adults, pregnant patients, older adults, or most children because its effects are clinically insignificant,³² residual sedation has been reported,⁶⁰ and no analysis of harms has been undertaken.³² Despite this, melatonin is frequently utilized for insomnia, and patients take over-the-counter melatonin for a myriad of sleep complaints. Melatonin is indicated in the treatment of insomnia in children with neurodevelopmental disorders. (See discussion in "Prescribing for children.")

Hypnotics are medications licensed for short-term sleep promotion in adults and can induce tolerance and dependence.³² Nonbenzodiazepine-receptor agonists at clinical doses do not appear to suppress REM sleep, although there are reports of increases in latency to REM sleep.⁷⁰

Antidepressants. Although treatment of insomnia with antidepressants is widespread, evidence of their efficacy is unclear.^32,62 The tolerability and safety of antidepressants for insomnia also are uncertain due to limited reporting of adverse events.³²

The use of sedating antidepressants may be driven by concern over the longer-term use of hypnotics and the limited availability of psychological treatments including CBT-I.³² Sedating antidepressants are indicated for comorbid or secondary insomnia (attributable to mental health conditions, medical conditions, other sleep disorders, or substance use or misuse); however, there are few clinical trials studying them for primary insomnia treatment.⁶² Antidepressants—tricyclic antidepressants included—can reduce the amount of REM sleep and increase REM sleep-onset latency.^71,72

Antihistamines and antipsychotics. Although antihistamines (eg, hydroxyzine, diphenhydramine) and antipsychotics frequently are prescribed off-label for primary insomnia, there is a lack of evidence to support either type of medication for this purpose.^36,62,73 H1-antihistamines such as hydroxyzine increase REM-onset latency and reduce the duration of REM sleep.⁷³ Depending on the specific medication, second-generation antipsychotics such as olanzapine and quetiapine have mixed effects on REM sleep parameters.⁶⁵

Continue to: Prescribing for children